Re: Outpatient 30 minute evaluations ???

[Guest guest]

Steve,

I think it was Hegadus (please correct me if I'm wrong), who once

wrote an editorial about a troubling shift of therapists trying to

become more and more specific with their evaluations (e.g. what is

wrong with this patient?) as opposed to spending a few minutes

developing a HYPOTHESIS of what may be wrong with the patient, and

spending the rest of the session trying to prove oneself wrong. In

other words, an evaluation should be an exercise in SENSITIVITY, not

specificity. By my math, with practice, it takes 8 to 10 minutes to

complete a good quarter screening, 5-15 to evaluate the biomechanical

problem, and 5-10 to define the difference between the pain that

brings the patient to you, and the functional problem for which

insurance will cover (and physical therapy truly is focused). That's

35 minute evaluation (assuming it's straight-forward), leaving 10

minutes for therex or manual initial treatment.

I don't see how it can be done any faster than that without missing a

silent, and potentially serious, issue.

--

M. Ball, PT, DPT, PhD, MBA

Carolinas Rehabilitation, Orthopaedic Physical Therapy Residency Faculty

NorthEast Rehabiltation, Staff Physical Therapist

Phuzion Institute for Physiotherapy Education, President

cell:

[Guest guest]

Hi Steve,

I would agree with you that 30 minute evaluation slots are not enough to

ensure a comprehensive evaluation and HEP instruction. There could be a

rare case with a straightforward problem such as an ankle sprain, but my

opinion is that would be an exception rather than the rule, especially

with the documentation standards we uphold. Does your friend feel the

documentation would be done in the same 30-minute slot as well? If not,

putting the documentation off until later in the day could result in

forgetting to document important patient comments or findings. Maybe

some can, but I wouldn't be able to manage patients that way.

Proffitt, PT

Outpatient

Ohio

From: PTManager [mailto:PTManager ] On

Behalf Of kptasteve

Sent: Tuesday, February 14, 2012 1:31 PM

To: PTManager

Subject: Outpatient 30 minute evaluations ???

Another physical therapist and I were discussing time needed for

outpatient evaluations. In my opinion, it is not possible to do a

complete evaluation along with home exercises in 30 minute evaluation

slots. My friend on the other hand, feels, that this is indeed possible

and given the present enviroment with health care we need to be moving

towards this. I feel very uncomfortable with this and feel that it

places the therapist at risk for missing critical information during the

evaluation process. I would appreciate knowing how others feel regarding

this.

Thank you,

Steve Marcum PT

Lexington, KY

Outpatient Orthopedic

[Guest guest]

Hi Steve,

I would agree with you that 30 minute evaluation slots are not enough to

ensure a comprehensive evaluation and HEP instruction. There could be a

rare case with a straightforward problem such as an ankle sprain, but my

opinion is that would be an exception rather than the rule, especially

with the documentation standards we uphold. Does your friend feel the

documentation would be done in the same 30-minute slot as well? If not,

putting the documentation off until later in the day could result in

forgetting to document important patient comments or findings. Maybe

some can, but I wouldn't be able to manage patients that way.

Proffitt, PT

Outpatient

Ohio

From: PTManager [mailto:PTManager ] On

Behalf Of kptasteve

Sent: Tuesday, February 14, 2012 1:31 PM

To: PTManager

Subject: Outpatient 30 minute evaluations ???

Another physical therapist and I were discussing time needed for

outpatient evaluations. In my opinion, it is not possible to do a

complete evaluation along with home exercises in 30 minute evaluation

slots. My friend on the other hand, feels, that this is indeed possible

and given the present enviroment with health care we need to be moving

towards this. I feel very uncomfortable with this and feel that it

places the therapist at risk for missing critical information during the

evaluation process. I would appreciate knowing how others feel regarding

this.

Thank you,

Steve Marcum PT

Lexington, KY

Outpatient Orthopedic

[Guest guest]

Dear Group:

with the utmost respect for everyone’s opinions & beliefs, I feel I still, at

the risk of sounding rude and blunt, must say that physical therapists are

sounding more dogmatic then the college of cardinals in the Vatican. For the

existence of this profession in this country we have been so damn brain washed

into measuring units of time, units of range, units of force, units of payment

that we forget it is all artificial and purely arbitrary. AND, in spite of this

very dogmatic doctrine of establishment acknowledging ONE THING that IS NOT time

based in terms of reimbursement is one’s evaluation, because of the array of

variables that fall into it, not in the least the amount of experience and

confidence of the evaluator, some of us [most of us] must still box ourselves

into this nonsensical arbitrary forms of thinking.

Length of time and “quality†are not synonymous, in either way of the

equation. I can tell you, the patient wants all they can get in the shortest

amount of time it can be done. Not to compare too much, but the surgeon will

spend 7.5 minutes with the patient in order to do his/her entire dog & pony show

AND document it, get paid 6 times what it will take us ONE HOUR(?!) to do

including his/her documentation time and the patient will still deposit more

value to what the surgeon provided even if at the end of the day we provided

more good for the buck.

We must step out of the box. We must get detached from time shackles and false

beliefs and we must sell value and not time.

Respectfully;

Armin Loges, PT

Tampa, FL

From: Ball

Sent: Tuesday, February 14, 2012 3:04 PM

To: PTManager

Subject: Re: Outpatient 30 minute evaluations ???

Steve,

I think it was Hegadus (please correct me if I'm wrong), who once

wrote an editorial about a troubling shift of therapists trying to

become more and more specific with their evaluations (e.g. what is

wrong with this patient?) as opposed to spending a few minutes

developing a HYPOTHESIS of what may be wrong with the patient, and

spending the rest of the session trying to prove oneself wrong. In

other words, an evaluation should be an exercise in SENSITIVITY, not

specificity. By my math, with practice, it takes 8 to 10 minutes to

complete a good quarter screening, 5-15 to evaluate the biomechanical

problem, and 5-10 to define the difference between the pain that

brings the patient to you, and the functional problem for which

insurance will cover (and physical therapy truly is focused). That's

35 minute evaluation (assuming it's straight-forward), leaving 10

minutes for therex or manual initial treatment.

I don't see how it can be done any faster than that without missing a

silent, and potentially serious, issue.

--

M. Ball, PT, DPT, PhD, MBA

Carolinas Rehabilitation, Orthopaedic Physical Therapy Residency Faculty

NorthEast Rehabiltation, Staff Physical Therapist

Phuzion Institute for Physiotherapy Education, President

cell:

[Guest guest]

Dear Group:

with the utmost respect for everyone’s opinions & beliefs, I feel I still, at

the risk of sounding rude and blunt, must say that physical therapists are

sounding more dogmatic then the college of cardinals in the Vatican. For the

existence of this profession in this country we have been so damn brain washed

into measuring units of time, units of range, units of force, units of payment

that we forget it is all artificial and purely arbitrary. AND, in spite of this

very dogmatic doctrine of establishment acknowledging ONE THING that IS NOT time

based in terms of reimbursement is one’s evaluation, because of the array of

variables that fall into it, not in the least the amount of experience and

confidence of the evaluator, some of us [most of us] must still box ourselves

into this nonsensical arbitrary forms of thinking.

Length of time and “quality†are not synonymous, in either way of the

equation. I can tell you, the patient wants all they can get in the shortest

amount of time it can be done. Not to compare too much, but the surgeon will

spend 7.5 minutes with the patient in order to do his/her entire dog & pony show

AND document it, get paid 6 times what it will take us ONE HOUR(?!) to do

including his/her documentation time and the patient will still deposit more

value to what the surgeon provided even if at the end of the day we provided

more good for the buck.

We must step out of the box. We must get detached from time shackles and false

beliefs and we must sell value and not time.

Respectfully;

Armin Loges, PT

Tampa, FL

From: Ball

Sent: Tuesday, February 14, 2012 3:04 PM

To: PTManager

Subject: Re: Outpatient 30 minute evaluations ???

Steve,

I think it was Hegadus (please correct me if I'm wrong), who once

wrote an editorial about a troubling shift of therapists trying to

become more and more specific with their evaluations (e.g. what is

wrong with this patient?) as opposed to spending a few minutes

developing a HYPOTHESIS of what may be wrong with the patient, and

spending the rest of the session trying to prove oneself wrong. In

other words, an evaluation should be an exercise in SENSITIVITY, not

specificity. By my math, with practice, it takes 8 to 10 minutes to

complete a good quarter screening, 5-15 to evaluate the biomechanical

problem, and 5-10 to define the difference between the pain that

brings the patient to you, and the functional problem for which

insurance will cover (and physical therapy truly is focused). That's

35 minute evaluation (assuming it's straight-forward), leaving 10

minutes for therex or manual initial treatment.

I don't see how it can be done any faster than that without missing a

silent, and potentially serious, issue.

--

M. Ball, PT, DPT, PhD, MBA

Carolinas Rehabilitation, Orthopaedic Physical Therapy Residency Faculty

NorthEast Rehabiltation, Staff Physical Therapist

Phuzion Institute for Physiotherapy Education, President

cell:

[Guest guest]

Armin,

God Bless you for that reponse.....I couldnt've said it any better.

Mike Rizkalla, NJ

On Tue, Feb 14, 2012 at 4:40 PM, Armin Loges wrote:

> **

>

>

> Dear Group:

>

> with the utmost respect for everyone’s opinions & beliefs, I feel I still,

> at the risk of sounding rude and blunt, must say that physical therapists

> are sounding more dogmatic then the college of cardinals in the Vatican.

> For the existence of this profession in this country we have been so damn

> brain washed into measuring units of time, units of range, units of force,

> units of payment that we forget it is all artificial and purely arbitrary.

> AND, in spite of this very dogmatic doctrine of establishment acknowledging

> ONE THING that IS NOT time based in terms of reimbursement is one’s

> evaluation, because of the array of variables that fall into it, not in the

> least the amount of experience and confidence of the evaluator, some of us

> [most of us] must still box ourselves into this nonsensical arbitrary forms

> of thinking.

> Length of time and “quality” are not synonymous, in either way of the

> equation. I can tell you, the patient wants all they can get in the

> shortest amount of time it can be done. Not to compare too much, but the

> surgeon will spend 7.5 minutes with the patient in order to do his/her

> entire dog & pony show AND document it, get paid 6 times what it will take us

> ONE HOUR(?!) to do including his/her documentation time and the patient

> will still deposit more value to what the surgeon provided even if at the

> end of the day we provided more good for the buck.

> We must step out of the box. We must get detached from time shackles and

> false beliefs and we must sell value and not time.

>

> Respectfully;

>

> Armin Loges, PT

> Tampa, FL

>

> From: Ball

> Sent: Tuesday, February 14, 2012 3:04 PM

> To: PTManager

> Subject: Re: Outpatient 30 minute evaluations ???

>

>

> Steve,

>

> I think it was Hegadus (please correct me if I'm wrong), who once

> wrote an editorial about a troubling shift of therapists trying to

> become more and more specific with their evaluations (e.g. what is

> wrong with this patient?) as opposed to spending a few minutes

> developing a HYPOTHESIS of what may be wrong with the patient, and

> spending the rest of the session trying to prove oneself wrong. In

> other words, an evaluation should be an exercise in SENSITIVITY, not

> specificity. By my math, with practice, it takes 8 to 10 minutes to

> complete a good quarter screening, 5-15 to evaluate the biomechanical

> problem, and 5-10 to define the difference between the pain that

> brings the patient to you, and the functional problem for which

> insurance will cover (and physical therapy truly is focused). That's

> 35 minute evaluation (assuming it's straight-forward), leaving 10

> minutes for therex or manual initial treatment.

>

> I don't see how it can be done any faster than that without missing a

> silent, and potentially serious, issue.

>

> --

> M. Ball, PT, DPT, PhD, MBA

> Carolinas Rehabilitation, Orthopaedic Physical Therapy Residency Faculty

> NorthEast Rehabiltation, Staff Physical Therapist

> Phuzion Institute for Physiotherapy Education, President

> cell:

>

>

[Guest guest]

Armin,

God Bless you for that reponse.....I couldnt've said it any better.

Mike Rizkalla, NJ

On Tue, Feb 14, 2012 at 4:40 PM, Armin Loges wrote:

> **

>

>

> Dear Group:

>

> with the utmost respect for everyone’s opinions & beliefs, I feel I still,

> at the risk of sounding rude and blunt, must say that physical therapists

> are sounding more dogmatic then the college of cardinals in the Vatican.

> For the existence of this profession in this country we have been so damn

> brain washed into measuring units of time, units of range, units of force,

> units of payment that we forget it is all artificial and purely arbitrary.

> AND, in spite of this very dogmatic doctrine of establishment acknowledging

> ONE THING that IS NOT time based in terms of reimbursement is one’s

> evaluation, because of the array of variables that fall into it, not in the

> least the amount of experience and confidence of the evaluator, some of us

> [most of us] must still box ourselves into this nonsensical arbitrary forms

> of thinking.

> Length of time and “quality” are not synonymous, in either way of the

> equation. I can tell you, the patient wants all they can get in the

> shortest amount of time it can be done. Not to compare too much, but the

> surgeon will spend 7.5 minutes with the patient in order to do his/her

> entire dog & pony show AND document it, get paid 6 times what it will take us

> ONE HOUR(?!) to do including his/her documentation time and the patient

> will still deposit more value to what the surgeon provided even if at the

> end of the day we provided more good for the buck.

> We must step out of the box. We must get detached from time shackles and

> false beliefs and we must sell value and not time.

>

> Respectfully;

>

> Armin Loges, PT

> Tampa, FL

>

> From: Ball

> Sent: Tuesday, February 14, 2012 3:04 PM

> To: PTManager

> Subject: Re: Outpatient 30 minute evaluations ???

>

>

> Steve,

>

> I think it was Hegadus (please correct me if I'm wrong), who once

> wrote an editorial about a troubling shift of therapists trying to

> become more and more specific with their evaluations (e.g. what is

> wrong with this patient?) as opposed to spending a few minutes

> developing a HYPOTHESIS of what may be wrong with the patient, and

> spending the rest of the session trying to prove oneself wrong. In

> other words, an evaluation should be an exercise in SENSITIVITY, not

> specificity. By my math, with practice, it takes 8 to 10 minutes to

> complete a good quarter screening, 5-15 to evaluate the biomechanical

> problem, and 5-10 to define the difference between the pain that

> brings the patient to you, and the functional problem for which

> insurance will cover (and physical therapy truly is focused). That's

> 35 minute evaluation (assuming it's straight-forward), leaving 10

> minutes for therex or manual initial treatment.

>

> I don't see how it can be done any faster than that without missing a

> silent, and potentially serious, issue.

>

> --

> M. Ball, PT, DPT, PhD, MBA

> Carolinas Rehabilitation, Orthopaedic Physical Therapy Residency Faculty

> NorthEast Rehabiltation, Staff Physical Therapist

> Phuzion Institute for Physiotherapy Education, President

> cell:

>

>

[Guest guest]

Armin,

God Bless you for that reponse.....I couldnt've said it any better.

Mike Rizkalla, NJ

On Tue, Feb 14, 2012 at 4:40 PM, Armin Loges wrote:

> **

>

>

> Dear Group:

>

> with the utmost respect for everyone’s opinions & beliefs, I feel I still,

> at the risk of sounding rude and blunt, must say that physical therapists

> are sounding more dogmatic then the college of cardinals in the Vatican.

> For the existence of this profession in this country we have been so damn

> brain washed into measuring units of time, units of range, units of force,

> units of payment that we forget it is all artificial and purely arbitrary.

> AND, in spite of this very dogmatic doctrine of establishment acknowledging

> ONE THING that IS NOT time based in terms of reimbursement is one’s

> evaluation, because of the array of variables that fall into it, not in the

> least the amount of experience and confidence of the evaluator, some of us

> [most of us] must still box ourselves into this nonsensical arbitrary forms

> of thinking.

> Length of time and “quality” are not synonymous, in either way of the

> equation. I can tell you, the patient wants all they can get in the

> shortest amount of time it can be done. Not to compare too much, but the

> surgeon will spend 7.5 minutes with the patient in order to do his/her

> entire dog & pony show AND document it, get paid 6 times what it will take us

> ONE HOUR(?!) to do including his/her documentation time and the patient

> will still deposit more value to what the surgeon provided even if at the

> end of the day we provided more good for the buck.

> We must step out of the box. We must get detached from time shackles and

> false beliefs and we must sell value and not time.

>

> Respectfully;

>

> Armin Loges, PT

> Tampa, FL

>

> From: Ball

> Sent: Tuesday, February 14, 2012 3:04 PM

> To: PTManager

> Subject: Re: Outpatient 30 minute evaluations ???

>

>

> Steve,

>

> I think it was Hegadus (please correct me if I'm wrong), who once

> wrote an editorial about a troubling shift of therapists trying to

> become more and more specific with their evaluations (e.g. what is

> wrong with this patient?) as opposed to spending a few minutes

> developing a HYPOTHESIS of what may be wrong with the patient, and

> spending the rest of the session trying to prove oneself wrong. In

> other words, an evaluation should be an exercise in SENSITIVITY, not

> specificity. By my math, with practice, it takes 8 to 10 minutes to

> complete a good quarter screening, 5-15 to evaluate the biomechanical

> problem, and 5-10 to define the difference between the pain that

> brings the patient to you, and the functional problem for which

> insurance will cover (and physical therapy truly is focused). That's

> 35 minute evaluation (assuming it's straight-forward), leaving 10

> minutes for therex or manual initial treatment.

>

> I don't see how it can be done any faster than that without missing a

> silent, and potentially serious, issue.

>

> --

> M. Ball, PT, DPT, PhD, MBA

> Carolinas Rehabilitation, Orthopaedic Physical Therapy Residency Faculty

> NorthEast Rehabiltation, Staff Physical Therapist

> Phuzion Institute for Physiotherapy Education, President

> cell:

>

>

[Guest guest]

" but the surgeon will spend 7.5 minutes with the patient in order to do

his/her entire dog & pony show AND document it, get paid 6 times what it will

take us ONE HOUR "

I feel confident that *if* the surgeon you speak of above actually did *only

spend 7.5 minutes* with the patient before he went into surgery, he would

not last very long without *making a critical mistake*. The issue here I am

speaking about is what is needed to indeed think critically, and provide a

comprehensive evaluation that prevents overlooking red flags and possible

alternative causes to the problem list. As Dr. Ball presented quite well "

spending a few minutes developing a HYPOTHESIS of what may be wrong with

the patient, and spending the rest of the session trying to prove oneself

wrong. In other words, an evaluation should be an exercise in SENSITIVITY,

not

specificity. "

Respectfully,

Steve Marcum PT

Lexington, KY

Outpatient Orthopedics

--

“Anyone who lives a sedentary life and does not exercise, even if he eats

good foods and takes care of himself according to proper medical

principles, all his days will be painful ones and his strength shall wane.”

Maimonides, 1199 AD

[Guest guest]

Steve, I have to agree that it is very possible to schedule patients for a 30

minute evaluation. At that visit, it is reasonable to discuss the patient's

chief complaint and evaluate that complaint. I do not think it is necessary to

complete all aspects of the evaluation on the first visit. A good therapist

should have a scan exam that they perform to cover the red flags and

contraindications to certain treatments. One can perform a very good

evaluation and do some patient teaching and give them a few things to do at

home. But, you have to let of some habits and really focus on the reason why

the patients is in your office. Every follow up visit should include a

reassessment and additional tests/measurements to cover everything completely.

Post op patients are a great example. A post op knee or shoulder and many

orthopedic problems are very easy to evaluate in 30 minutes. I would agree that

neurological, vestibular/balance and some Women's Health patients need more

time. Those patients should be scheduled for 45 or 60 minute evals. When

there will be millions more patients who have coverage that will not reimburse

very well, cutting to the chase quickly will be imperative. I really fought

this myself in the 80's when managed care hit Oregon hard. When I stopped

fighting it and accepted it, I became a much better clinician as I had less time

per visit and fewer visits to get the same good results I had achieved before.

From: PTManager [mailto:PTManager ] On Behalf Of

kptasteve

Sent: Tuesday, February 14, 2012 10:31 AM

To: PTManager

Subject: Outpatient 30 minute evaluations ???

Another physical therapist and I were discussing time needed for outpatient

evaluations. In my opinion, it is not possible to do a complete evaluation along

with home exercises in 30 minute evaluation slots. My friend on the other hand,

feels, that this is indeed possible and given the present enviroment with health

care we need to be moving towards this. I feel very uncomfortable with this and

feel that it places the therapist at risk for missing critical information

during the evaluation process. I would appreciate knowing how others feel

regarding this.

Thank you,

Steve Marcum PT

Lexington, KY

Outpatient Orthopedic

________________________________

This message is intended for the sole use of the addressee, and may contain

information that is privileged, confidential and exempt from disclosure under

applicable law. If you are not the addressee you are hereby notified that you

may not use, copy, disclose, or distribute to anyone the message or any

information contained in the message. If you have received this message in

error, please immediately advise the sender by reply email and delete this

message.

[Guest guest]

Steve, I have to agree that it is very possible to schedule patients for a 30

minute evaluation. At that visit, it is reasonable to discuss the patient's

chief complaint and evaluate that complaint. I do not think it is necessary to

complete all aspects of the evaluation on the first visit. A good therapist

should have a scan exam that they perform to cover the red flags and

contraindications to certain treatments. One can perform a very good

evaluation and do some patient teaching and give them a few things to do at

home. But, you have to let of some habits and really focus on the reason why

the patients is in your office. Every follow up visit should include a

reassessment and additional tests/measurements to cover everything completely.

Post op patients are a great example. A post op knee or shoulder and many

orthopedic problems are very easy to evaluate in 30 minutes. I would agree that

neurological, vestibular/balance and some Women's Health patients need more

time. Those patients should be scheduled for 45 or 60 minute evals. When

there will be millions more patients who have coverage that will not reimburse

very well, cutting to the chase quickly will be imperative. I really fought

this myself in the 80's when managed care hit Oregon hard. When I stopped

fighting it and accepted it, I became a much better clinician as I had less time

per visit and fewer visits to get the same good results I had achieved before.

From: PTManager [mailto:PTManager ] On Behalf Of

kptasteve

Sent: Tuesday, February 14, 2012 10:31 AM

To: PTManager

Subject: Outpatient 30 minute evaluations ???

Another physical therapist and I were discussing time needed for outpatient

evaluations. In my opinion, it is not possible to do a complete evaluation along

with home exercises in 30 minute evaluation slots. My friend on the other hand,

feels, that this is indeed possible and given the present enviroment with health

care we need to be moving towards this. I feel very uncomfortable with this and

feel that it places the therapist at risk for missing critical information

during the evaluation process. I would appreciate knowing how others feel

regarding this.

Thank you,

Steve Marcum PT

Lexington, KY

Outpatient Orthopedic

________________________________

This message is intended for the sole use of the addressee, and may contain

information that is privileged, confidential and exempt from disclosure under

applicable law. If you are not the addressee you are hereby notified that you

may not use, copy, disclose, or distribute to anyone the message or any

information contained in the message. If you have received this message in

error, please immediately advise the sender by reply email and delete this

message.

[Guest guest]

Steve, I have to agree that it is very possible to schedule patients for a 30

minute evaluation. At that visit, it is reasonable to discuss the patient's

chief complaint and evaluate that complaint. I do not think it is necessary to

complete all aspects of the evaluation on the first visit. A good therapist

should have a scan exam that they perform to cover the red flags and

contraindications to certain treatments. One can perform a very good

evaluation and do some patient teaching and give them a few things to do at

home. But, you have to let of some habits and really focus on the reason why

the patients is in your office. Every follow up visit should include a

reassessment and additional tests/measurements to cover everything completely.

Post op patients are a great example. A post op knee or shoulder and many

orthopedic problems are very easy to evaluate in 30 minutes. I would agree that

neurological, vestibular/balance and some Women's Health patients need more

time. Those patients should be scheduled for 45 or 60 minute evals. When

there will be millions more patients who have coverage that will not reimburse

very well, cutting to the chase quickly will be imperative. I really fought

this myself in the 80's when managed care hit Oregon hard. When I stopped

fighting it and accepted it, I became a much better clinician as I had less time

per visit and fewer visits to get the same good results I had achieved before.

From: PTManager [mailto:PTManager ] On Behalf Of

kptasteve

Sent: Tuesday, February 14, 2012 10:31 AM

To: PTManager

Subject: Outpatient 30 minute evaluations ???

Another physical therapist and I were discussing time needed for outpatient

evaluations. In my opinion, it is not possible to do a complete evaluation along

with home exercises in 30 minute evaluation slots. My friend on the other hand,

feels, that this is indeed possible and given the present enviroment with health

care we need to be moving towards this. I feel very uncomfortable with this and

feel that it places the therapist at risk for missing critical information

during the evaluation process. I would appreciate knowing how others feel

regarding this.

Thank you,

Steve Marcum PT

Lexington, KY

Outpatient Orthopedic

________________________________

This message is intended for the sole use of the addressee, and may contain

information that is privileged, confidential and exempt from disclosure under

applicable law. If you are not the addressee you are hereby notified that you

may not use, copy, disclose, or distribute to anyone the message or any

information contained in the message. If you have received this message in

error, please immediately advise the sender by reply email and delete this

message.

[Guest guest]

, that is a good point about not having to compete the entire eval in a

angle session --- unless you are using an EMR that requires completion within 72

hours before sealing the note. Also, if you do half of an evaluation and bill

for it with the expectation that it will be competed later, and the patient

falls ill and dies before completion of the evaluation ....

Armin, you are right that SOME specific evals can be completed in 30 min, but

I'd hate to be the patient with gall bladder referred pain and a RTC tear, or

the patient with a herniated disk and osteomyelitis that came In to see THAT PT!

Just some additional food for thought.

M. Ball, PT, DPT, PhD

Carolinas Rehabilitation

Orthopedic PT Resident

Charlotte/Concord, NC

On Feb 14, 2012, at 6:19 PM, " Zarosinski, "

wrote:

> Steve, I have to agree that it is very possible to schedule patients for a 30

minute evaluation. At that visit, it is reasonable to discuss the patient's

chief complaint and evaluate that complaint. I do not think it is necessary to

complete all aspects of the evaluation on the first visit. A good therapist

should have a scan exam that they perform to cover the red flags and

contraindications to certain treatments. One can perform a very good evaluation

and do some patient teaching and give them a few things to do at home. But, you

have to let of some habits and really focus on the reason why the patients is in

your office. Every follow up visit should include a reassessment and additional

tests/measurements to cover everything completely. Post op patients are a great

example. A post op knee or shoulder and many orthopedic problems are very easy

to evaluate in 30 minutes. I would agree that neurological, vestibular/balance

and some Women's Health patients need more time. Those patients should be

scheduled for 45 or 60 minute evals. When there will be millions more patients

who have coverage that will not reimburse very well, cutting to the chase

quickly will be imperative. I really fought this myself in the 80's when managed

care hit Oregon hard. When I stopped fighting it and accepted it, I became a

much better clinician as I had less time per visit and fewer visits to get the

same good results I had achieved before.

>

> From: PTManager [mailto:PTManager ] On Behalf

Of kptasteve

> Sent: Tuesday, February 14, 2012 10:31 AM

> To: PTManager

> Subject: Outpatient 30 minute evaluations ???

>

> Another physical therapist and I were discussing time needed for outpatient

evaluations. In my opinion, it is not possible to do a complete evaluation along

with home exercises in 30 minute evaluation slots. My friend on the other hand,

feels, that this is indeed possible and given the present enviroment with health

care we need to be moving towards this. I feel very uncomfortable with this and

feel that it places the therapist at risk for missing critical information

during the evaluation process. I would appreciate knowing how others feel

regarding this.

>

> Thank you,

>

> Steve Marcum PT

> Lexington, KY

> Outpatient Orthopedic

>

> ________________________________

> This message is intended for the sole use of the addressee, and may contain

information that is privileged, confidential and exempt from disclosure under

applicable law. If you are not the addressee you are hereby notified that you

may not use, copy, disclose, or distribute to anyone the message or any

information contained in the message. If you have received this message in

error, please immediately advise the sender by reply email and delete this

message.

>

>

[Guest guest]

, that is a good point about not having to compete the entire eval in a

angle session --- unless you are using an EMR that requires completion within 72

hours before sealing the note. Also, if you do half of an evaluation and bill

for it with the expectation that it will be competed later, and the patient

falls ill and dies before completion of the evaluation ....

Armin, you are right that SOME specific evals can be completed in 30 min, but

I'd hate to be the patient with gall bladder referred pain and a RTC tear, or

the patient with a herniated disk and osteomyelitis that came In to see THAT PT!

Just some additional food for thought.

M. Ball, PT, DPT, PhD

Carolinas Rehabilitation

Orthopedic PT Resident

Charlotte/Concord, NC

On Feb 14, 2012, at 6:19 PM, " Zarosinski, "

wrote:

> Steve, I have to agree that it is very possible to schedule patients for a 30

minute evaluation. At that visit, it is reasonable to discuss the patient's

chief complaint and evaluate that complaint. I do not think it is necessary to

complete all aspects of the evaluation on the first visit. A good therapist

should have a scan exam that they perform to cover the red flags and

contraindications to certain treatments. One can perform a very good evaluation

and do some patient teaching and give them a few things to do at home. But, you

have to let of some habits and really focus on the reason why the patients is in

your office. Every follow up visit should include a reassessment and additional

tests/measurements to cover everything completely. Post op patients are a great

example. A post op knee or shoulder and many orthopedic problems are very easy

to evaluate in 30 minutes. I would agree that neurological, vestibular/balance

and some Women's Health patients need more time. Those patients should be

scheduled for 45 or 60 minute evals. When there will be millions more patients

who have coverage that will not reimburse very well, cutting to the chase

quickly will be imperative. I really fought this myself in the 80's when managed

care hit Oregon hard. When I stopped fighting it and accepted it, I became a

much better clinician as I had less time per visit and fewer visits to get the

same good results I had achieved before.

>

> From: PTManager [mailto:PTManager ] On Behalf

Of kptasteve

> Sent: Tuesday, February 14, 2012 10:31 AM

> To: PTManager

> Subject: Outpatient 30 minute evaluations ???

>

> Another physical therapist and I were discussing time needed for outpatient

evaluations. In my opinion, it is not possible to do a complete evaluation along

with home exercises in 30 minute evaluation slots. My friend on the other hand,

feels, that this is indeed possible and given the present enviroment with health

care we need to be moving towards this. I feel very uncomfortable with this and

feel that it places the therapist at risk for missing critical information

during the evaluation process. I would appreciate knowing how others feel

regarding this.

>

> Thank you,

>

> Steve Marcum PT

> Lexington, KY

> Outpatient Orthopedic

>

> ________________________________

> This message is intended for the sole use of the addressee, and may contain

information that is privileged, confidential and exempt from disclosure under

applicable law. If you are not the addressee you are hereby notified that you

may not use, copy, disclose, or distribute to anyone the message or any

information contained in the message. If you have received this message in

error, please immediately advise the sender by reply email and delete this

message.

>

>

[Guest guest]

(and entire group):

You are associating that it takes that long (whatever time it may take: 30 min,

60 min, 90 min, or simply 2 min) to " not miss " serious morbidities, when such is

irrelevant to the amount of minutes you have slotted. Could you be implying (?)

that if the therapist would suspect cholelithiasis, or kidney stones, AAA or

osteo or whatever the case maybe, but the time slot was not long enough, that

this therapist would say to him/herself " oh my, i should really ask this patient

more questions or confirm my findings, but unfortunately i dont have the time

allotted ... " when the day to day truth around these united states is this

patient already came from one referral to another, most times through the PCP

and the ortho/neuro - and although these things could still have been missed

(and yes Steve, I was being generous on the 7.5 minutes, as we all know - but I

was referring to the office visit and not the day of the surgery), it still

should not take any extra long to rule these things out, reason why we review

systems and rule our physical examination against the interview and the PMHx.

That being said, in the fortunate cases of " direct access " , the pt will be yours

to screen and have all the fun.

Being that I am in private practice and get the luxury of deciding whatever time

I want to take to do whatever I want to do, many times taking the length of one

hour or thereabouts has more to do with the fact that my schedule is slow and I

am truly enjoying the pt-PT interaction and taking my sweet time than anything

else. Nonetheless, my point was the majority of time, what really happens does

not need to take long, unless one left school yesterday and is deciding if the

goniometer is indicating 78 degrees or actually 81 degrees ( i am just making a

point, please no one take any offense on this remark). The truth is PTs have the

[bad] habit of associating length of duration with " quality " of service. We

typically get paid for " time " provided, rather then for " results obtained " , a

big mistake of our acceptance - in my opinion. If thats the case we can't get

mad when we get compared to massage therapists or personal trainers! Whatever

the " red flags " they are called red flags because they jump right in our faces,

waving (!) and all you need to do is acknowledge them as they are. No extra time

needed other than to say " dear Mrs. , I find something a little of my

concern, which may actually be beyond the scope of my practice and I would like

you to schedule an appointment with Dr. So & so and please take this note to him

etc etc " .

Besides the love affair with time, should I also bring about the love affair

about writing goals to this discussion?

Just kidding (but not...lol) a its off topic...

Armin Loges, PT

Respectfully from Tampa, FL

Armin Loges, PT

This message and any of its attachments is private, confidential & privileged

information intended solely for the named addressee(s). It may contain Private

Health Information (PHI) protected under HIPAA law and must be handled as such.

If you received this message in error, delete it and all it's attachments and

inform this sender for remedial measures. Thank you.

> , that is a good point about not having to compete the entire eval in a

angle session --- unless you are using an EMR that requires completion within 72

hours before sealing the note. Also, if you do half of an evaluation and bill

for it with the expectation that it will be competed later, and the patient

falls ill and dies before completion of the evaluation ....

>

> Armin, you are right that SOME specific evals can be completed in 30 min, but

I'd hate to be the patient with gall bladder referred pain and a RTC tear, or

the patient with a herniated disk and osteomyelitis that came In to see THAT PT!

>

> Just some additional food for thought.

>

> M. Ball, PT, DPT, PhD

> Carolinas Rehabilitation

> Orthopedic PT Resident

> Charlotte/Concord, NC

>

> On Feb 14, 2012, at 6:19 PM, " Zarosinski, "

wrote:

>

> > Steve, I have to agree that it is very possible to schedule patients for a

30 minute evaluation. At that visit, it is reasonable to discuss the patient's

chief complaint and evaluate that complaint. I do not think it is necessary to

complete all aspects of the evaluation on the first visit. A good therapist

should have a scan exam that they perform to cover the red flags and

contraindications to certain treatments. One can perform a very good evaluation

and do some patient teaching and give them a few things to do at home. But, you

have to let of some habits and really focus on the reason why the patients is in

your office. Every follow up visit should include a reassessment and additional

tests/measurements to cover everything completely. Post op patients are a great

example. A post op knee or shoulder and many orthopedic problems are very easy

to evaluate in 30 minutes. I would agree that neurological, vestibular/balance

and some Women's Health patients need more time. Those patients should be

scheduled for 45 or 60 minute evals. When there will be millions more patients

who have coverage that will not reimburse very well, cutting to the chase

quickly will be imperative. I really fought this myself in the 80's when managed

care hit Oregon hard. When I stopped fighting it and accepted it, I became a

much better clinician as I had less time per visit and fewer visits to get the

same good results I had achieved before.

> >

> > From: PTManager [mailto:PTManager ] On Behalf

Of kptasteve

> > Sent: Tuesday, February 14, 2012 10:31 AM

> > To: PTManager

> > Subject: Outpatient 30 minute evaluations ???

> >

> > Another physical therapist and I were discussing time needed for outpatient

evaluations. In my opinion, it is not possible to do a complete evaluation along

with home exercises in 30 minute evaluation slots. My friend on the other hand,

feels, that this is indeed possible and given the present enviroment with health

care we need to be moving towards this. I feel very uncomfortable with this and

feel that it places the therapist at risk for missing critical information

during the evaluation process. I would appreciate knowing how others feel

regarding this.

> >

> > Thank you,

> >

> > Steve Marcum PT

> > Lexington, KY

> > Outpatient Orthopedic

> >

> > ________________________________

> > This message is intended for the sole use of the addressee, and may contain

information that is privileged, confidential and exempt from disclosure under

applicable law. If you are not the addressee you are hereby notified that you

may not use, copy, disclose, or distribute to anyone the message or any

information contained in the message. If you have received this message in

error, please immediately advise the sender by reply email and delete this

message.

> >

> >

[Guest guest]

Armin,

I actually agree with quite a few of your points. Chief among them, you

have a point with respect to the erroneous association of time spent with

patient and quality of service. That said, I find it interesting, that

it's usually the same therapists making this argument that make similarly

erroneous association between years of experience and the quality of the

services that they provide, or the value of experience against the DPT,

residency, or fellowship programs. Afterall, it's not the years of

experience that matter, but rather the quality of experiences contained

within those years . . . 20 years practice isn't all that valuable if it's

the same year over and over again. My point is that therapists tend to set

their bar of acceptable professional practice at just below what they

themselves are doing (saves the time of actually doing true professional

self-reflection I suppose), but it's rarely truly in the optimal interests

of the profession or the patients we serve.

You are more than correct that, " We typically get paid for " time " provided,

rather then for " results obtained " , a big mistake of our acceptance - in my

opinion. If thats the case we can't get mad when we get compared to massage

therapists or personal trainers! " I couldn't agree more, but the fact is

that it DOES take some measure of time to complete a quality evaluation,

and the shorter the time of that evaluation, the greater the CHANCE that

something potentially sinister gets missed. At the very least,

silent culprit impairments that better explain the noisy victim patient

complaint are overlooked --- resulting in an inarguable compromise to

efficiency of care at best, and quality of care at worst.

I can promise only this . . . you can be an acceptable therapist for most

patients doing 30 minute evaluations, but such a therapist simply can't

know what he or she has missed, both from a MSK perspective and a medical

referral perspective. That therapist may have never seen a AAA causing a

patient's back pain, or weak hip abductors that contributed to the

patient's inability to react and avoid the plant-and-twist and valgus force

that resulted in an ACL injury --- but I PROMISE that the shorter an

evaluation, the more likely those sinister pathology and silent

MSK culprits are to have seen the therapist (e.g. they existed but the

therapist simply missed). I'm sure there are therapists out there thinking

" Hey, I do 15 minute evaluations and I caught a (whatever) last week. " To

those therapists I say, " Congratulations, you were lucky, go buy a lottery

ticket on the basis of one true positive you found, and don't worry about

the x number that you missed. "

All of this is to say . . . you've peaked my interested with the " Love

affair with writing goals, " statement, and I would welcome you opening a

new thread on that topic . . .

M. Ball, PT, DPT, PhD, MBA

Carolinas Rehabilitation, Orthopaedic Physical Therapy Residency Faculty

NorthEast Rehabiltation, Staff Physical Therapist

Phuzion Institute for Physiotherapy Education, President

cell:

[Guest guest]

Armin,

I actually agree with quite a few of your points. Chief among them, you

have a point with respect to the erroneous association of time spent with

patient and quality of service. That said, I find it interesting, that

it's usually the same therapists making this argument that make similarly

erroneous association between years of experience and the quality of the

services that they provide, or the value of experience against the DPT,

residency, or fellowship programs. Afterall, it's not the years of

experience that matter, but rather the quality of experiences contained

within those years . . . 20 years practice isn't all that valuable if it's

the same year over and over again. My point is that therapists tend to set

their bar of acceptable professional practice at just below what they

themselves are doing (saves the time of actually doing true professional

self-reflection I suppose), but it's rarely truly in the optimal interests

of the profession or the patients we serve.

You are more than correct that, " We typically get paid for " time " provided,

rather then for " results obtained " , a big mistake of our acceptance - in my

opinion. If thats the case we can't get mad when we get compared to massage

therapists or personal trainers! " I couldn't agree more, but the fact is

that it DOES take some measure of time to complete a quality evaluation,

and the shorter the time of that evaluation, the greater the CHANCE that

something potentially sinister gets missed. At the very least,

silent culprit impairments that better explain the noisy victim patient

complaint are overlooked --- resulting in an inarguable compromise to

efficiency of care at best, and quality of care at worst.

I can promise only this . . . you can be an acceptable therapist for most

patients doing 30 minute evaluations, but such a therapist simply can't

know what he or she has missed, both from a MSK perspective and a medical

referral perspective. That therapist may have never seen a AAA causing a

patient's back pain, or weak hip abductors that contributed to the

patient's inability to react and avoid the plant-and-twist and valgus force

that resulted in an ACL injury --- but I PROMISE that the shorter an

evaluation, the more likely those sinister pathology and silent

MSK culprits are to have seen the therapist (e.g. they existed but the

therapist simply missed). I'm sure there are therapists out there thinking

" Hey, I do 15 minute evaluations and I caught a (whatever) last week. " To

those therapists I say, " Congratulations, you were lucky, go buy a lottery

ticket on the basis of one true positive you found, and don't worry about

the x number that you missed. "

All of this is to say . . . you've peaked my interested with the " Love

affair with writing goals, " statement, and I would welcome you opening a

new thread on that topic . . .

M. Ball, PT, DPT, PhD, MBA

Carolinas Rehabilitation, Orthopaedic Physical Therapy Residency Faculty

NorthEast Rehabiltation, Staff Physical Therapist

Phuzion Institute for Physiotherapy Education, President

cell:

[Guest guest]

Armin,

I actually agree with quite a few of your points. Chief among them, you

have a point with respect to the erroneous association of time spent with

patient and quality of service. That said, I find it interesting, that

it's usually the same therapists making this argument that make similarly

erroneous association between years of experience and the quality of the

services that they provide, or the value of experience against the DPT,

residency, or fellowship programs. Afterall, it's not the years of

experience that matter, but rather the quality of experiences contained

within those years . . . 20 years practice isn't all that valuable if it's

the same year over and over again. My point is that therapists tend to set

their bar of acceptable professional practice at just below what they

themselves are doing (saves the time of actually doing true professional

self-reflection I suppose), but it's rarely truly in the optimal interests

of the profession or the patients we serve.

You are more than correct that, " We typically get paid for " time " provided,

rather then for " results obtained " , a big mistake of our acceptance - in my

opinion. If thats the case we can't get mad when we get compared to massage

therapists or personal trainers! " I couldn't agree more, but the fact is

that it DOES take some measure of time to complete a quality evaluation,

and the shorter the time of that evaluation, the greater the CHANCE that

something potentially sinister gets missed. At the very least,

silent culprit impairments that better explain the noisy victim patient

complaint are overlooked --- resulting in an inarguable compromise to

efficiency of care at best, and quality of care at worst.

I can promise only this . . . you can be an acceptable therapist for most

patients doing 30 minute evaluations, but such a therapist simply can't

know what he or she has missed, both from a MSK perspective and a medical

referral perspective. That therapist may have never seen a AAA causing a

patient's back pain, or weak hip abductors that contributed to the

patient's inability to react and avoid the plant-and-twist and valgus force

that resulted in an ACL injury --- but I PROMISE that the shorter an

evaluation, the more likely those sinister pathology and silent

MSK culprits are to have seen the therapist (e.g. they existed but the

therapist simply missed). I'm sure there are therapists out there thinking

" Hey, I do 15 minute evaluations and I caught a (whatever) last week. " To

those therapists I say, " Congratulations, you were lucky, go buy a lottery

ticket on the basis of one true positive you found, and don't worry about

the x number that you missed. "

All of this is to say . . . you've peaked my interested with the " Love

affair with writing goals, " statement, and I would welcome you opening a

new thread on that topic . . .

M. Ball, PT, DPT, PhD, MBA

Carolinas Rehabilitation, Orthopaedic Physical Therapy Residency Faculty

NorthEast Rehabiltation, Staff Physical Therapist

Phuzion Institute for Physiotherapy Education, President

cell:

[Guest guest]

I love this country (smiling), and I love this site because of the almost

guarantee that you will be able to get many points of view.

Armin, I must say I agree with a great deal of what you say, and in a

clinic where I can control everything, I think that I could schedule my

evaluations every 30 minutes. I agree sometimes all things come together

during the evaluation, and the subsequent development of the plan of care,

(you are right the goals thing can be a wonderful thread).

However, there are other points that need to be considered with this

discussion. Just one is the idea of finishing up the evaluation on the

subsequent visit may sound viable, but when the patient has a co-pay in

the $40 to $50 dollar range, they don't want to have to come back numerous

times. They want their evaluation done completely and a individualized

program developed that they can take home. They should expect this

individualized program to reflect the full consideration of the problem, of

why they came to a Physical Therapist in the first place. This component

(the individualised training and program) is one of the considerations in

my developing my work flow " budget " , I am addressing the time to teach

and explain to the patient what fundamentally is at the core of their

problem. Providing the time to teach and explain the exacerbating and

perpetuating factors are so that the patient can take control of his or her

own home program.

I agree with you Armin, my knowledge and skill are not timed values. The

evaluation is basically the product of my experience and knowledge base.

The analytical and algorithmic process is as advertised by Mastercard

" priceless " . Sometimes it takes 5 minutes to reach a conclusion. Other

times, even when all the medical record is provided, I am faced with a

complex medically challenged patient. This what separates us from the

massage therapist, the personal trainers, and the athletic trainers. These

medically based considerations are what physcial therapists point to when

promoting the difference.

What I am working at to illustrate is that,( in my own personal workflow),

it takes more that 30 minutes to provide the evaluation *and* then provide

the training in 30 minutes. I don't think scheduling evaluations every

30 minutes allows for my workflow to accomplish what I feel is necessary to

complete this process.

--

“Anyone who lives a sedentary life and does not exercise, even if he eats

good foods and takes care of himself according to proper medical

principles, all his days will be painful ones and his strength shall wane.”

Maimonides, 1199 AD

[Guest guest]

Beautifully stated Armin and I couldn't agree more. The issue, I think, gets

brought up in terms of PT staffing, revenue and productivity when PTs feel

pressures by the constraints of their schedule and by the demands of

productivity goals and benchmarks but none of these pressures should ever

supercede the needs of the patient sitting in that seat across from you. In our

staff meetings we focus on doing the best we can for that patient in the time

allotted, that is all any of us can do.

E s, PT, DPT, OCS, FAAOMPT

Www.douglasspt.com

> >

> > > Steve, I have to agree that it is very possible to schedule patients for a

30 minute evaluation. At that visit, it is reasonable to discuss the patient's

chief complaint and evaluate that complaint. I do not think it is necessary to

complete all aspects of the evaluation on the first visit. A good therapist

should have a scan exam that they perform to cover the red flags and

contraindications to certain treatments. One can perform a very good evaluation

and do some patient teaching and give them a few things to do at home. But, you

have to let of some habits and really focus on the reason why the patients is in

your office. Every follow up visit should include a reassessment and additional

tests/measurements to cover everything completely. Post op patients are a great

example. A post op knee or shoulder and many orthopedic problems are very easy

to evaluate in 30 minutes. I would agree that neurological, vestibular/balance

and some Women's Health patients need more time. Those patients should be

scheduled for 45 or 60 minute evals. When there will be millions more patients

who have coverage that will not reimburse very well, cutting to the chase

quickly will be imperative. I really fought this myself in the 80's when managed

care hit Oregon hard. When I stopped fighting it and accepted it, I became a

much better clinician as I had less time per visit and fewer visits to get the

same good results I had achieved before.

> > >

> > > From: PTManager [mailto:PTManager ] On

Behalf Of kptasteve

> > > Sent: Tuesday, February 14, 2012 10:31 AM

> > > To: PTManager

> > > Subject: Outpatient 30 minute evaluations ???

> > >

> > > Another physical therapist and I were discussing time needed for

outpatient evaluations. In my opinion, it is not possible to do a complete

evaluation along with home exercises in 30 minute evaluation slots. My friend on

the other hand, feels, that this is indeed possible and given the present

enviroment with health care we need to be moving towards this. I feel very

uncomfortable with this and feel that it places the therapist at risk for

missing critical information during the evaluation process. I would appreciate

knowing how others feel regarding this.

> > >

> > > Thank you,

> > >

> > > Steve Marcum PT

> > > Lexington, KY

> > > Outpatient Orthopedic

> > >

> > > ________________________________

> > > This message is intended for the sole use of the addressee, and may

contain information that is privileged, confidential and exempt from disclosure

under applicable law. If you are not the addressee you are hereby notified that

you may not use, copy, disclose, or distribute to anyone the message or any

information contained in the message. If you have received this message in

error, please immediately advise the sender by reply email and delete this

message.

> > >

> > >

[Guest guest]

Beautifully stated Armin and I couldn't agree more. The issue, I think, gets

brought up in terms of PT staffing, revenue and productivity when PTs feel

pressures by the constraints of their schedule and by the demands of

productivity goals and benchmarks but none of these pressures should ever

supercede the needs of the patient sitting in that seat across from you. In our

staff meetings we focus on doing the best we can for that patient in the time

allotted, that is all any of us can do.

E s, PT, DPT, OCS, FAAOMPT

Www.douglasspt.com

> >

> > > Steve, I have to agree that it is very possible to schedule patients for a

30 minute evaluation. At that visit, it is reasonable to discuss the patient's

chief complaint and evaluate that complaint. I do not think it is necessary to

complete all aspects of the evaluation on the first visit. A good therapist

should have a scan exam that they perform to cover the red flags and

contraindications to certain treatments. One can perform a very good evaluation

and do some patient teaching and give them a few things to do at home. But, you

have to let of some habits and really focus on the reason why the patients is in

your office. Every follow up visit should include a reassessment and additional

tests/measurements to cover everything completely. Post op patients are a great

example. A post op knee or shoulder and many orthopedic problems are very easy

to evaluate in 30 minutes. I would agree that neurological, vestibular/balance

and some Women's Health patients need more time. Those patients should be

scheduled for 45 or 60 minute evals. When there will be millions more patients

who have coverage that will not reimburse very well, cutting to the chase

quickly will be imperative. I really fought this myself in the 80's when managed

care hit Oregon hard. When I stopped fighting it and accepted it, I became a

much better clinician as I had less time per visit and fewer visits to get the

same good results I had achieved before.

> > >

> > > From: PTManager [mailto:PTManager ] On

Behalf Of kptasteve

> > > Sent: Tuesday, February 14, 2012 10:31 AM

> > > To: PTManager

> > > Subject: Outpatient 30 minute evaluations ???

> > >

> > > Another physical therapist and I were discussing time needed for

outpatient evaluations. In my opinion, it is not possible to do a complete

evaluation along with home exercises in 30 minute evaluation slots. My friend on

the other hand, feels, that this is indeed possible and given the present

enviroment with health care we need to be moving towards this. I feel very

uncomfortable with this and feel that it places the therapist at risk for

missing critical information during the evaluation process. I would appreciate

knowing how others feel regarding this.

> > >

> > > Thank you,

> > >

> > > Steve Marcum PT

> > > Lexington, KY

> > > Outpatient Orthopedic

> > >

> > > ________________________________

> > > This message is intended for the sole use of the addressee, and may

contain information that is privileged, confidential and exempt from disclosure

under applicable law. If you are not the addressee you are hereby notified that

you may not use, copy, disclose, or distribute to anyone the message or any

information contained in the message. If you have received this message in

error, please immediately advise the sender by reply email and delete this

message.

> > >

> > >

[Guest guest]

To all,

I sat in the Accountable Care organizations lecture at CSM in Chicago last

week......Thursday at 8am.

This lecture was very , very eye opening.

Let me caution everyone , this overall topic will soon be under much scrutiny.

As a profession , we need a united position, or someone else will find it for

us.

E. Lynn MS PT

Director of Rehabilitation

Marlton Rehabilitation Hospital

92 Brick Rd.

Marlton, NJ 08055

ext 4204

From: PTManager [mailto:PTManager ] On Behalf Of

Ball

Sent: Tuesday, February 14, 2012 9:20 PM

To: PTManager

Subject: Re: Outpatient 30 minute evaluations ???

Armin,

I actually agree with quite a few of your points. Chief among them, you

have a point with respect to the erroneous association of time spent with

patient and quality of service. That said, I find it interesting, that

it's usually the same therapists making this argument that make similarly

erroneous association between years of experience and the quality of the

services that they provide, or the value of experience against the DPT,

residency, or fellowship programs. Afterall, it's not the years of

experience that matter, but rather the quality of experiences contained

within those years . . . 20 years practice isn't all that valuable if it's

the same year over and over again. My point is that therapists tend to set

their bar of acceptable professional practice at just below what they

themselves are doing (saves the time of actually doing true professional

self-reflection I suppose), but it's rarely truly in the optimal interests

of the profession or the patients we serve.

You are more than correct that, " We typically get paid for " time " provided,

rather then for " results obtained " , a big mistake of our acceptance - in my

opinion. If thats the case we can't get mad when we get compared to massage

therapists or personal trainers! " I couldn't agree more, but the fact is

that it DOES take some measure of time to complete a quality evaluation,

and the shorter the time of that evaluation, the greater the CHANCE that

something potentially sinister gets missed. At the very least,

silent culprit impairments that better explain the noisy victim patient

complaint are overlooked --- resulting in an inarguable compromise to

efficiency of care at best, and quality of care at worst.

I can promise only this . . . you can be an acceptable therapist for most

patients doing 30 minute evaluations, but such a therapist simply can't

know what he or she has missed, both from a MSK perspective and a medical

referral perspective. That therapist may have never seen a AAA causing a

patient's back pain, or weak hip abductors that contributed to the

patient's inability to react and avoid the plant-and-twist and valgus force

that resulted in an ACL injury --- but I PROMISE that the shorter an

evaluation, the more likely those sinister pathology and silent

MSK culprits are to have seen the therapist (e.g. they existed but the

therapist simply missed). I'm sure there are therapists out there thinking

" Hey, I do 15 minute evaluations and I caught a (whatever) last week. " To

those therapists I say, " Congratulations, you were lucky, go buy a lottery

ticket on the basis of one true positive you found, and don't worry about

the x number that you missed. "

All of this is to say . . . you've peaked my interested with the " Love

affair with writing goals, " statement, and I would welcome you opening a

new thread on that topic . . .

M. Ball, PT, DPT, PhD, MBA

Carolinas Rehabilitation, Orthopaedic Physical Therapy Residency Faculty

NorthEast Rehabiltation, Staff Physical Therapist

Phuzion Institute for Physiotherapy Education, President

cell:

[Guest guest]

I don't know , if what you state with regards to lack of time spent during

an evaluation increasing the likelihood that you will miss something as so much

of our professional development takes place, or should take place, outside of

patient care. If you don't know how to identify non mechanical low back pain

then it won't matter how much time you spend. If you are aware of the CPR for

identification of DVT potential then this can be assessed almost before you

actually see the patient but if you are going to pop the patient up on the

stationary bike before you have even looked at his chart (believe me, it

happens) then no amount of time is going to save you, or him, from yourself.

Time vs likelihood of missing red flags, would make an interesting study.

E s, PT, DPT, OCS, FAAOMPT

www.douglasspt.com

>

> Armin,

>

> I actually agree with quite a few of your points. Chief among them, you

> have a point with respect to the erroneous association of time spent with

> patient and quality of service. That said, I find it interesting, that

> it's usually the same therapists making this argument that make similarly

> erroneous association between years of experience and the quality of the

> services that they provide, or the value of experience against the DPT,

> residency, or fellowship programs. Afterall, it's not the years of

> experience that matter, but rather the quality of experiences contained

> within those years . . . 20 years practice isn't all that valuable if it's

> the same year over and over again. My point is that therapists tend to set

> their bar of acceptable professional practice at just below what they

> themselves are doing (saves the time of actually doing true professional

> self-reflection I suppose), but it's rarely truly in the optimal interests

> of the profession or the patients we serve.

>

> You are more than correct that, " We typically get paid for " time " provided,

> rather then for " results obtained " , a big mistake of our acceptance - in my

> opinion. If thats the case we can't get mad when we get compared to massage

> therapists or personal trainers! " I couldn't agree more, but the fact is

> that it DOES take some measure of time to complete a quality evaluation,

> and the shorter the time of that evaluation, the greater the CHANCE that

> something potentially sinister gets missed. At the very least,

> silent culprit impairments that better explain the noisy victim patient

> complaint are overlooked --- resulting in an inarguable compromise to

> efficiency of care at best, and quality of care at worst.

>

> I can promise only this . . . you can be an acceptable therapist for most

> patients doing 30 minute evaluations, but such a therapist simply can't

> know what he or she has missed, both from a MSK perspective and a medical

> referral perspective. That therapist may have never seen a AAA causing a

> patient's back pain, or weak hip abductors that contributed to the

> patient's inability to react and avoid the plant-and-twist and valgus force

> that resulted in an ACL injury --- but I PROMISE that the shorter an

> evaluation, the more likely those sinister pathology and silent

> MSK culprits are to have seen the therapist (e.g. they existed but the

> therapist simply missed). I'm sure there are therapists out there thinking

> " Hey, I do 15 minute evaluations and I caught a (whatever) last week. " To

> those therapists I say, " Congratulations, you were lucky, go buy a lottery

> ticket on the basis of one true positive you found, and don't worry about

> the x number that you missed. "

>

> All of this is to say . . . you've peaked my interested with the " Love

> affair with writing goals, " statement, and I would welcome you opening a

> new thread on that topic . . .

>

> M. Ball, PT, DPT, PhD, MBA

> Carolinas Rehabilitation, Orthopaedic Physical Therapy Residency Faculty

> NorthEast Rehabiltation, Staff Physical Therapist

> Phuzion Institute for Physiotherapy Education, President

> cell:

>

>

>

[Guest guest]

and Steve: I have a feeling we actually agree on more than it looks like

at first sight.

I have a feeling this thread initiated as a means to help someone organize their

department and their schedule policies.

I, however, nearly always go on the “principle†tangent, disregarding the

simply logistic day to day operations of corporatized situations intentionally.

I believe we are all PTs first and employees (or whatever else, ie. contractors

etc) second. So I apologize to Steve if we monopolize and change route on the

whole thread.

: off course you and I agree that experience and “old age†or time at

work does not amount to expertise. It is the same principle of time spent on the

evaluation, in sorts, wouldn’t you think?

Steve: I get you allegiance to the patient and respect for his financial and

time investment. I think this is a trend amongst us, the respect for the

patient more so than we see in other fields. I get it. But on my routine of

going on principle, I believe – perhaps due to the downfalls of our

educational systems, that it is all a gradient of time/space and not black nor

white. In other words “does the evaluation starts. the evaluation ends. the

treatment starts. the discharge comes?â€. Very academic. But in my opinion

nothing further from the truth. Perhaps how I saw it when I left school, but

the older I get the less it looks like that. Nonetheless, I am forced to write

something. Title it Evaluation. Then I am forced again to write time and time

again and title it daily notes. Then I am forced to write and end to the story

and title it Discharge. Very compartmentalized. But our thought processes

should not in fact that way. We evaluate the patient every damn day. Or at least

we should. We are planning DC from day one. etc etc etc.

Goals? On a slow day.

Armin Loges, PT

Tampa, FL

From: Ball

Sent: Tuesday, February 14, 2012 9:20 PM

To: PTManager

Subject: Re: Outpatient 30 minute evaluations ???

Armin,

I actually agree with quite a few of your points. Chief among them, you

have a point with respect to the erroneous association of time spent with

patient and quality of service. That said, I find it interesting, that

it's usually the same therapists making this argument that make similarly

erroneous association between years of experience and the quality of the

services that they provide, or the value of experience against the DPT,

residency, or fellowship programs. Afterall, it's not the years of

experience that matter, but rather the quality of experiences contained

within those years . . . 20 years practice isn't all that valuable if it's

the same year over and over again. My point is that therapists tend to set

their bar of acceptable professional practice at just below what they

themselves are doing (saves the time of actually doing true professional

self-reflection I suppose), but it's rarely truly in the optimal interests

of the profession or the patients we serve.

You are more than correct that, " We typically get paid for " time " provided,

rather then for " results obtained " , a big mistake of our acceptance - in my

opinion. If thats the case we can't get mad when we get compared to massage

therapists or personal trainers! " I couldn't agree more, but the fact is

that it DOES take some measure of time to complete a quality evaluation,

and the shorter the time of that evaluation, the greater the CHANCE that

something potentially sinister gets missed. At the very least,

silent culprit impairments that better explain the noisy victim patient

complaint are overlooked --- resulting in an inarguable compromise to

efficiency of care at best, and quality of care at worst.

I can promise only this . . . you can be an acceptable therapist for most

patients doing 30 minute evaluations, but such a therapist simply can't

know what he or she has missed, both from a MSK perspective and a medical

referral perspective. That therapist may have never seen a AAA causing a

patient's back pain, or weak hip abductors that contributed to the

patient's inability to react and avoid the plant-and-twist and valgus force

that resulted in an ACL injury --- but I PROMISE that the shorter an

evaluation, the more likely those sinister pathology and silent

MSK culprits are to have seen the therapist (e.g. they existed but the

therapist simply missed). I'm sure there are therapists out there thinking

" Hey, I do 15 minute evaluations and I caught a (whatever) last week. " To

those therapists I say, " Congratulations, you were lucky, go buy a lottery

ticket on the basis of one true positive you found, and don't worry about

the x number that you missed. "

All of this is to say . . . you've peaked my interested with the " Love

affair with writing goals, " statement, and I would welcome you opening a

new thread on that topic . . .

M. Ball, PT, DPT, PhD, MBA

Carolinas Rehabilitation, Orthopaedic Physical Therapy Residency Faculty

NorthEast Rehabiltation, Staff Physical Therapist

Phuzion Institute for Physiotherapy Education, President

cell:

[Guest guest]

1) could you please provide a summary of " Let me caution everyone ,

this overall topic will soon be under much scrutiny.

As a profession , we need a united position, or someone else will find it

for us. "

2) So I agree with Dr, Ball and Dr. Armin Loges PT; and

philosophically speaking that would be the course to follow. However, I

would now like suggestions on how to provide a workable schedule. Do, you

have tiered evaluations, with some sort of pre-knowledge of the complexity

of the patient, and schedule this type of patient into the 30 minute slots,

and have longer slots for more complicated say for neurological evaluations

Thanks and again respectfully

Steve Marcum PT

Lexington, KY

(mostly [?]) Orthopedic Outpatient

“Anyone who lives a sedentary life and does not exercise, even if he eats

good foods and takes care of himself according to proper medical

principles, all his days will be painful ones and his strength shall wane.”

Maimonides, 1199 AD